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SAFEWAY INC
CAH031302-00 NORTHERN COCHISE COMMUNITY HOSPITAL, INC.
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Covered Entity Details
Entity Name
NORTHERN COCHISE COMMUNITY HOSPITAL, INC.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031302-00
Entity Address
901 WEST REX ALLEN DRIVE
WILLCOX, AZ 85643
Medicare Provider Number
031302
Participating Start Date
8/5/2010
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1275
599 WEST 4TH STREET
BENSON, AZ 85602
Pharmacy Comments
Contract Details
Approval Date
1/13/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Roland Knox, CHIEF EXECUTIVE OFFICER
(520) 766-6465
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
1/13/2017
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